Bronchial Asthma

• A chronic inflammatory disease of the airway that causes airway hyperresponsiveness, mucosal edema and
excessive mucus production.
• With acute exacerbations but is largely reversible
• Also known as Reactive Airway Disease (RAD) and/or Reversible Obstructive Airway Disease

Etiologic Agents
A. Extrinsic
 Inhalants - hydrochloric acid, ammonia, and heated plastic fumes, Sulfur dioxide, oxides of nitrogen,
and ozone
 Ingestants – drugs (aspirin)
 Contactants
 Temperature Changes
 Biological -- respiratory syncytial virus, rhinovirus, influenza, parainfluenza
 Smoking

B. Intrinsic
 Fatigue
 Stress / Anxiety

Predisposing Factors
• Allergy
• Environment – air pollution
• Activities – exercise and athletics – increase heat loss, rapid ventilation, increase severity of exercise and
inhalation of cold dry air
• Existing Respiratory Conditions – URTI, croup, cystic fibrosis (others: osteoporosis, cataract, GERD)
• Gender: Female > Male

Pathophysiology

1. Etiologic Agent + Predisposing factors (Allergens)

2. Inflammation (thromboxanes, histamines, leukotrienes, prostaglandins)
3. Swelling of mucous membranes (mucosal edema)
4. Reduction of airway diameter
5. Contraction of bronchial smooth muscles
6. Further narrowing of the airways
7. Increase mucus production
8. Mucus plug in bronchi
9. Clinical Manifestations

Diagnostic Tests
1. Pulmonary Function test
2. Peak flow measurements
3. CT-scan of the lungs
4. Chest X ray
5. CBC
6. Arterial Blood gas

Clinical Manifestations
1. Cough
2. Wheezing
3. Dyspnea
4. Stridor
5. Tachypnea
6. Tachycardia
7. Chest pain/tightness
8. Intercostal retractions
 Severity of acute asthma exacerbations[13]
Near-fatal asthma High PaCO2 and/or requiring mechanical ventilation
Any one of the following in a person with severe asthma:-
Clinical signs Measurements
Altered conscious level Peak flow < 33%
Exhaustion Oxygen saturation < 92%
Life threatening asthma Arrhythmia PaO2 < 8 kPa
Low blood pressure "Normal" PaCO2
Cyanosis
Silent chest
Poor respiratory effort
Any one of:-
Peak flow 33-50%
Acute severe asthma Respiratory rate ≥ 25 breaths per minute
Heart rate ≥ 110 beats per minute
Unable to complete sentences in one breath
Worsening symptoms
Moderate asthma exacerbation Peak flow > 50% best or predicted
No features of acute severe asthma

Classification
1. Immunologic Asthma/Atopic Asthma
• Occurs in childhood r/t allergens; “Allergic asthma” or atopic asthma; heredity; high lgE
• Most common
2. Non-Immunologic/Non-Atopic Asthma
• Occurs in adulthood, usually associated with URTI or LRTI
• “Non-allergic asthma” or non-atopic asthma;
• onset usually > 35 years
• Occupational-related, Cough-Variant related, Exercise-related.
3. Mixed Asthma
• Any age; any allergen; non-specific stimuli

Severity Symptom frequency Nighttime symptoms %FEV1 of predicted FEV1 Variability

Intermittent <1 per week ≤2 per month ≥80% <20%
Mild persistent >1 per week >2 per month ≥80% 20–30%
but <1 per day
Moderate persistent Daily >1 per week 60–80% >30%
Severe persistent Daily Frequent <60% >30%

Nursing Diagnosis

1. Ineffective airway clearance related to increased mucus secretions in the tracheobronchial tree secondary to
inflammation.
2. Ineffective breathing pattern related to decreased airway diameter secondary to mucosal edema and
bronchoconstriction.
3. Impaired gas exchange related to alterred breathing pattern secondary to airway constriction.

Management
A. Dependent
Pharmacotherapy:
1. Bronchodilators – to relieve bronchospasm
2. Theophylline – check pulse and blood pressure
3. Beta-Adrenergic agents: rapid onset of actions when administered by aerosol
4. Corticosteroids to relieve inflammation and edema
5. Antibiotics – if secondary infection
6. Cromolyn sodium – inhaled; inhibits histamine release in the lungs and prevents attack
7. Short-acting bronchodilators – proventil, ventolin, Xopenex
 8. Mucolytics

B. Independent
1. Position: ORTHOPNEIC POSITION
2. PURSED LIP BREATHING
3. Encourage Oral Fluid Intake
4. Support and monitor oxygenation status
5. Assess for respiratory acidosis
6. Administer medications, as ordered
7. Administer nebulizer as ordered
8. Provide patient teaching about preventing attacks and proper use of medications

Complication
• Status Asthmaticus – severe and persistent asthma that does not respond to medications.
• Goal: Avoid intubation
• NR: Epinephrine at bedside
• Monitor hydration and oxygenation status

Client Teaching
1. Compliance to pharmacotherapy
• Use of MDIs and nebulizers
2. Lifestyle modifications
• Quit smoking!
• Diet modifications
• Exercise regimen
3. Recognition of acute signs and symptoms
• Peak flow meters
• Incentive Spirometry

Ajbg/2008